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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEtTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ^� ��a�k-16p� a, City r1 o Lot Size acre PM <br /> Job Address . _ g Qq--AiZ <br /> $Gaffs5903-a <br /> �r yCj© � tnc Address Phone <br /> Owner's Name _�— <br /> License No. - Phone <br /> Contractor's Name € <br /> DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT ❑ UCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Delta �+ Depth of Grout Seal � Type of Grout <br /> Ll Public l ❑ Other � y �, �� ( <br /> rax. Depth DI ., Surface Seal Installed by �/ 1 <br /> ❑ Irrigation app <br /> iWor <br /> State k=Done <br /> Repair Work Done :1 Type of Pump H.P. 't <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Filler Material (Below 50'1 <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ED] (Noavaseptic sy t6m permittedfpubr,,--1w-ri1 <br /> Installation will serve: Residence✓ Commercial— Other <br /> Number of living units: �_ Number of bedrooms .— „t Character of soil to a depth of 3 feet: <br /> Water table depthSEPTIC TANK ❑ Type/Mf Capacity 1 O� Na. Compartments <br /> gMethodof•Disposal r-, <br /> 1 <br /> PKG. TREATMENT PLT. ❑ 1 / <br /> Distance to nearest: Well�_— Foundation '� 1� Property Line_++1� <br /> LEACHING LINE ❑ No. & Length of lines - 7-5 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Q�5 Foundation *.S Property Line <br /> a <br /> I <br /> SEEPAGE PITS El Depth � Size Number <br /> SUMPS, ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> rdance with San Joaquin county_ordinances, state laws, and <br /> i hereby certify that I have prepared this application and that the work will be done in acco <br /> rules and regulations of the San Joaquin Local Health District, at in the performance of the work which;till.sY <br /> permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify th <br /> employ any person in such manner as to become subject to workman's compensation laws of California. Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." d <br /> The applicant must call for all r quired inspections. Complete drawing on reverse side. b <br /> JQ �- Date: [ <br /> Signed Title:- <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> i ` -Area <br /> Date / ? <br /> Application Accepted by y� Date <br /> Pit or Grout inspection by Date'r Final Inspection by <br /> Additional Comments: <br /> y ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Returnall copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK# RECEIVED BY DATE PERMIT`NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> -4 <br /> + EH 1324(REV.10!631 <br /> EH 14-26 <br />